SoFHA
Patient Forms

MRI Screening


Description:

The SoFHA Imaging Center MRI screening form.


Code:

19.007

Issued:

01/01/2022

Revision:

1

Revised:

N/A

MRI Screening

















Female Only





Do you have any of the following implants inside or on your body?
























WARNING: Certain implants, devices or objects may be hazardous to you or may interfere with the MRI procedure. In rare cases, MRI can induce some heating of the body that could result in a burn. If you experience this or have any other problems, please inform the technologist.

You MUST remove & lock all listed items in a secure area: cell phone, watch, wallet, FitBit activity tracker, magnetic bracelets, keys, pocket knife, ankle weights, steel toed shoes, etc.

I attest that the above information is correct to the best of my knowledge. I understand that an image enhancement agent may be injected as part of this procedure. I was provided an IV contrast medication guide. I also consent to the release of radiographs, other imaging, post-op notes or reports from any facility if needed to help in the interpretation of this procedure.


Signature

By typing your name in the signature fields below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.